- Open Access
Prognostic value of resting myocardial contrast echocardiography: a meta-analysis
Echo Research & Practice volume 7, pages 19–28 (2020)
Background: Resting myocardial perfusion (MP) and wall motion (WM) imaging during real-time myocardial contrast echocardiography (MCE) improves the detection of coronary artery disease (CAD). However, its prognostic role in different clinical settings (emergency department and outpatient setting) remains unclear.
Methods: A systematic search in PubMed and Embase databases, and the Cochrane library, was conducted to evaluate the role of resting MP and WM in predicting major adverse cardiac events (MACE), including death, nonfatal myocardial infarction (NFMI) and urgent revascularization in patients presenting to either outpatient clinics or emergency departments with suspected symptomatic CAD. Summary receiver operating characteristic (SROC) curves, sensitivity and specificity plots were applied to assess diagnostic performance using RevMan 5.3.
Results: Seven studies met criteria, including 3668 patients (six with follow up ranging from 2 days to 2.6 years). The Relative Risk (RR) for predicting MACE in patients with both abnormal resting MP and WM was 6.1 (95% CI, 5.1–7.2) and 14.3 (95% CI, 10.3–19.8) for death/NFMI, when compared to normal resting MP and WM patients. Having both abnormal resting MP and WM was also more predictive of MACE (RR, 1.7; 95% CI 1.5–1.9) and death/NFMI (RR, 2.2; 95% CI, 1.8–2.7) when compared to abnormal WM with normal resting MP.
Conclusion: In this meta-analysis of both ED and outpatient clinic presentations for suspected CAD, having both a resting regional MP and WM abnormality identifies the highest risk patient for adverse events.
McMahon C, Yates DW, Hollis S. Unexpected mortality in patients discharged from the emergency department following an episode of nontraumatic chest pain. European Journal of Emergency Medicine 2008 15 3–8. (https://doi.org/10.1097/MEJ.0b013e32827b14cd)
Sun BC, Laurie A, Fu R, Ferencik M, Shapiro M, Lindsell CJ, Diercks D, Hoekstra JW, Hollander JE, Kirk JD, et al. Association of early stress testing with outcomes for emergency department evaluation of suspected acute coronary syndrome. Critical Pathways in Cardiology 2016 15 60–68. (https://doi.org/10.1097/HPC.0000000000000068)
Chase M, Robey JL, Zogby KE, Sease KL, Shofer FS, Hollander JE. Prospective validation of the thrombolysis in myocardial infarction risk score in the emergency department chest pain population. Annals of Emergency Medicine 2006 48 252–259. (https://doi.org/10.1016/j.annemergmed.2006.01.032)
Lee TH, Cook EF, Weisberg M, Sargent RK, Wilson C, Goldman L. Acute chest pain in the emergency room: identification and examination of low-risk patients. Archives of Internal Medicine 1985 145 65–69. (https://doi.org/10.1001/archinte.1985.00360010085013)
Selker HP, Griffith JL, D’agostino RB. A tool for judging coronary care unit admission appropriateness, valid for both real-time and retrospective use: a time-insensitive predictive instrument (TIPI) for acute cardiac ischemia: a multicenter study. Medical Care 1991 29 610–627. (https://doi.org/10.1097/00005650-199107000-00002)
Thomas D, Xie F, Smith LM, O’Leary E, Smith K, Olson J, Nalty K, Hess R, Graham M, Therrien S, et al. Prospective randomized comparison of conventional stress echocardiography and real-time perfusion stress echocardiography in detecting significant coronary artery disease. Journal of the American Society of Echocardiography 2012 25 1207–1214. (https://doi.org/10.1016/j.echo.2012.08.016)
Porter TR, Smith LM, Wu J, Thomas D, Haas JT, Mathers DH, Williams E, Olson J, Nalty K, Hess R, et al. Patient outcome following 2 different stress imaging approaches: a prospective randomized comparison. Journal of the American College of Cardiology 2013 61 2446–2455. (https://doi.org/10.1016/j.jacc.2013.04.019)
Tong KL, Kaul S, Wang XQ, Rinkevich D, Kalvaitis S, Belcik T, Lepper W, Foster WA, Wei K. Myocardial contrast echocardiography versus thrombolysis in myocardial infarction score in patients presenting to the emergency department with chest pain and a nondiagnostic electrocardiogram. Journal of the American College of Cardiology 2005 46 920–927. (https://doi.org/10.1016/j.jacc.2005.03.076)
Wei K, Peters D, Belcik T, Kalvaitis S, Womak L, Rinkevich D, Tong KL, Horton K, Kaul S. A predictive instrument using contrast echocardiography in patients presenting to the emergency department with chest pain and without ST-segment elevation. Journal of the American Society of Echocardiography 2010 23 636–642. (https://doi.org/10.1016/j.echo.2010.03.013)
Rinkevich D, Kaul S, Wang XQ, Tong KL, Belcik T, Kalvaitis S, Lepper W, Dent JM, Wei K. Regional left ventricular perfusion and function in patients presenting to the emergency department with chest pain and no ST-segment elevation. European Heart Journal 2005 26 1606–1611. (https://doi.org/10.1093/eurheartj/ehi335)
Kang DH, Kang SJ, Song JM, Choi KJ, Hong MK, Song JK, Park SW, Park SJ. Efficacy of myocardial contrast echocardiography in the diagnosis and risk stratification of acute coronary syndrome. American Journal of Cardiology 2005 96 1498–1502. (https://doi.org/10.1016/j.amjcard.2005.07.057)
Hagendorff A, Goeckritz A, Pfeiffer D, Becher H. Myocardial t echocardiography demonstrates myocardial hypoperfusion in the LAD territory in patients with acute chest pain at rest–a prospective study using power Doppler harmonic imaging with intravenous bolus application. European Journal of Echocardiography 2004 5 132–141. (https://doi.org/10.1016/S1525-2167(03)00055-6)
Kaul S, Senior R, Firschke C, Wang XQ, Lindner J, Villanueva FS, Firozan S, Kontos MC, Taylor A, Nixon IJ, et al. Incremental value of cardiac imaging in patients presenting to the emergency department with chest pain and without ST-segment elevation: a multicenter study. American Heart Journal 2004 148 129–136. (https://doi.org/10.1016/j.ahj.2003.12.041)
Korosoglou G, Labadze N, Hansen A, Selter C, Giannitsis E, Katus H, Kuecherer H. Usefulness of real-time myocardial perfusion imaging in the evaluation of patients with first time chest pain. American Journal of Cardiology 2004 94 1225–1231. (https://doi.org/10.1016/j.amjcard.2004.07.104)
Li X, He S, Zhang YS, Chen Y, He JC. Resting myocardial contrast echocardiography for the evaluation of coronary microcirculation dysfunction in patients with early coronary artery disease. Clinical Cardiology 2016 39 453–458. (https://doi.org/10.1002/clc.22548)
Laiq Z, Smith LM, Xie F, Chamsi-Pasha M, Porter TR. Differences in patient outcomes after conventional versus real time perfusion stress echocardiography in men versus women: a prospective randomized trial. Heart 2015 101 559–564. (https://doi.org/10.1136/heartjnl-2014-306869)
Kalvaitis S, Kaul S, Tong KL, Rinkevich D, Belcik T, Wei K. Effect of time delay on the diagnostic use of contrast echocardiography in patients presenting to the emergency department with chest pain and no S-T segment elevation. Journal of the American Society of Echocardiography 2006 19 1488–1493. (https://doi.org/10.1016/j.echo.2006.06.010)
Wyrick JJ, Kalvaitis S, McConnell KJ, Rinkevich D, Kaul S, Wei K. Cost-efficiency of myocardial contrast echocardiography in patients presenting to the emergency department with chest pain of suspected cardiac origin and a nondiagnostic electrocardiogram. American Journal of Cardiology 2008 102 649–652. (https://doi.org/10.1016/j.amjcard.2008.05.008)
Bailliez A, Lairez O, Merlin C, Piriou N, Legallois D, Blaire T, Agostini D, Valette F, Manrique A. Left ventricular function assessment using 2 different cadmium-zinc-telluride cameras compared with a γ-camera with cardiofocal collimators: dynamic cardiac phantom study and clinical validation. Journal of Nuclear Medicine 2016 57 1370–1375. (https://doi.org/10.2967/jnumed.115.168575)
Korosoglou G, Giusca S, Gitsioudis G, Erbel C, Katus HA. Cardiac magnetic resonance and computed tomography angiography for clinical imaging of stable coronary artery disease. Diagnostic classification and risk stratification. Frontiers in Physiology 2014 5 291. (https://doi.org/10.3389/fphys.2014.00291)
Rudolph A, Abdel-Aty H, Bohl S, Boyé P, Zagrosek A, Dietz R, Schulz-Menger J. Noninvasive detection of fibrosis applying contrast-enhanced cardiac magnetic resonance in different forms of left ventricular hypertrophy relation to remodeling. Journal of the American College of Cardiology 2009 53 284–291. (https://doi.org/10.1016/j.jacc.2008.08.064)
Mulvagh SL, Rakowski H, Vannan MA, Abdelmoneim SS, Becher H, Bierig SM, Burns PN, Castello R, Coon PD, Hagen ME, et al. American Society of Echocardiography consensus statement on the clinical applications of ultrasonic contrast agents in echocardiography. Journal of the American Society of Echocardiography 2008 21 1179–1201. quiz 1281. (https://doi.org/10.1016/j.echo.2008.09.009)
Porter TR, Mulvagh SL, Abdelmoneim SS, Becher H, Belcik JT, Bierig M, Choy J, Gaibazzi N, Gillam LD, Janardhanan R, et al. Clinical applications of ultrasonic enhancing agents in echocardiography: 2018 American Society of Echocardiography guidelines update. Journal of the American Society of Echocardiography 2018 31 241–274. (https://doi.org/10.1016/j.echo.2017.11.013)
Melki D, Lugnegard J, Alfredsson J, Lind S, Eggers KM, Lindahl B, Jernberg T. Implications of introducing high-sensitivity cardiac troponin T into clinical practice. Journal of the American College of Cardiology 2015 65 1655–1664. (https://doi.org/10.1016/j.jacc.2015.02.044)
Senior R, Becher H, Monaghan M, Agati L, Zamorano J, Vanoverschelde JL, Nihoyannopoulos P, Edvardsen T, Lancelloti P, EACVI Scientific Documents Committee for 2014–16 and 2016–18, et al. Clinical practice of contrast echocardiography: recommendation by the European Association of Cardiovascular Imaging (EACVI) 2017. European Heart Journal Cardiovascular Imaging 2017 18 1205–1205af. (https://doi.org/10.1093/ehjci/jex182)
The authors thank Alyssa Elwood for her administrative assistance with this manuscript.
This study was partially supported by the National Natural Science Foundation of China (Grant No. 81871359), by Jiangsu Provincial Key Discipline of Medicine (ZDXKA2016003), by the Natural Science Foundation of Jiangsu Province (BK20161057), by the Postgraduate Research & Practice Innovation Program of Jiangsu Province (KYCX18_1478) and the China Scholarship Council (201808320318). This was also supported by the Theodore F Hubbard Foundation at the University of Nebraska Medical Center.
About this article
Cite this article
Qian, L., Xie, F., Xu, D. et al. Prognostic value of resting myocardial contrast echocardiography: a meta-analysis. Echo Res Pract 7, 19–28 (2020). https://doi.org/10.1530/ERP-20-0023
- myocardial contrast echocardiography
- coronary artery disease